TCAR Technique TCAR Technique 29

Meticulous Angiographic Technique Conclusion

Use a low-and-slow technique to avoid high-pressure TCAR is an excellent procedure that has low injection next to the carotid lesion. Syringes for periprocedural rates in high-risk patients. injection should be loaded at the beginning of However, it should be remembered that this is a TCAR Pearls and Pitfalls the case to allow the bubbles of air to leave the relatively new procedure in which we continue to solution. Keep in mind that requires gain insights from expanding experience. In order to Michael C. Stoner, MD, RVT, FACS antegrade flow, and this is a potential source of distal maintain excellent results, practitioners should keep embolization. Avoid unnecessary imaging, especially themselves updated on the evolving best practices to Jeffrey Jim, MD, MPHS, FACS after the lesion has been treated. ensure the best clinical outcomes for their patients.

The information contained herein is for guidance based upon the author’s experience. Individual patient considerations should be taken Minimize Postdilation into account prior to treatment with TCAR. The authors advocate for a more generous predilation MICHAEL C. STONER, strategy, approaching a nominal internal carotid MD, RVT, FACS Transcarotid artery (TCAR) represents a novel, minimal-access technique diameter. This allows for better apposition and indicated for revascularization of the (ICA) in patients with clinically or reduces this risk of prolapsing atheromatous material Chief, Division of Vascular hemodynamically significant lesions. TCAR maintains the benefit of a minimally invasive procedure through the stent during postdilation. Furthermore, University of while mitigating much of the procedural embolization risk of traditional transfemoral-based stenting. disruption of the plaque earlier during the flow Rochester Medical Center The results of this procedure have been exceptional in both clinical trials and real-world registry reversal duration may be more protective for the Rochester, New York michael_ 1,2 studies. With over 12,000 cases completed to date, a robust evolving training program, and a patients. [email protected] culture of continuous improvement, the procedure continues to be optimized and improved. Disclosures: Case proctor and Always Use Protamine educational consultant for Silk The following learning points were recognized to aid novice users as well as experienced Road Medical. in practice for practitioners to achieve the excellent results seen in TCAR. The intra-arterial manipulation during TCAR mandates more than 20 years. a therapeutically heparinized patient. However, as Realize the Short, but Real, Learning Curve previously mentioned, the procedure time is quite short and the patient is likely to be fully anticoagulated TCAR leverages current skills of most endovascular surgeons (eg, carotid exposure, JEFFREY JIM, during incision closure. Cervical hematoma is a MD, MPHS, FACS with 0.014-inch platforms, and stenting). TCAR procedure times have consistently been shown risk that can be mitigated by both careful dissection to be almost 40 minutes less than standard carotid . However, this is still a new Associate Professor, Section and heparin reversal. Furthermore, the use of procedure for novel users. Meticulous procedural techniques are required to realize the efficiency of protamine has been shown to eliminate the risk of and achieve the safety of TCAR. Program Director, Vascular bleeding complications, but it was not associated with Surgery Fellowship/Residency 3 Take Time for Preoperative Case Planning increased stroke risk or other complications. Washington University School of Medicine St. Louis, Missouri Attention to the common carotid access site, lesion characteristics, distal ICA anatomy, and Diligent Intraoperative and Postoperative Blood [email protected] intracranial atherosclerotic burden is paramount to the success of this procedure. Careful Pressure Management Disclosures: Co-Director adherence to adequate anatomic requirements is necessary to ensure safe arterial sheath National TEST Drive Program, placement without engaging the lesion. Heavily calcified lesions should be avoided because of the The protective nature of TCAR is generating retrograde flow in the internal carotid artery during education consultant, and case known long- term adverse outcomes (eg, recurrence, thrombosis) with stent placements in these proctor for Silk Road Medical. types of lesions. treatment. Flow reversal and ipsilateral cerebral blood flow are both predicated on maintaining adequate References arterial pressure and relative hypertension during 1. Kwolek CJ, Jaff MR, Leal JI, et al. Results of the ROADSTER Medical Therapy Is the Cornerstone of Safety multicenter trial of transcarotid stenting with dynamic flow reversal. J the procedure. Proactive use of anti-bradyarrhythmia Vasc Surg. 2015;62:1227-1234. Violation of the drug regimen is one of the most common causes of the rare adverse events agents should be applied, and clear communication 2. Malas MB, Dakour-Aridi H, Wang GJ, et al. Transcarotid artery seen in TCAR. Angioplasty and stenting disrupts the intimal-medial interface, exposing blood revascularization versus transfemoral carotid artery stenting in the with the team regarding flow reversal Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. flow to a thrombogenic surface. All patients should be on dual antiplatelet therapy to prevent parameters is critical. Postoperatively, hyper- 2019;69:92-103.e2. platelet aggregation. therapy has also been shown to have plaque-stabilizing properties. and hypotension are to be avoided to prevent 3. Schermerhorn M. Transcarotid artery revascularization. Presented at: The beneficial use of these agents has been well-described in the literature and is considered as the Society of Vascular Surgery Vascular Annual Meeting; June 2019. hyperperfusion syndromes or stent thrombosis. standard of care. 28 TCAR Technique TCAR Technique

Meticulous Angiographic Technique Conclusion

Use a low-and-slow technique to avoid high-pressure TCAR is an excellent procedure that has low injection next to the carotid lesion. Syringes for periprocedural stroke rates in high-risk patients. injection should be loaded at the beginning of However, it should be remembered that this is a TCAR Pearls and Pitfalls the case to allow the bubbles of air to leave the relatively new procedure in which we continue to solution. Keep in mind that angiography requires gain insights from expanding experience. In order to Michael C. Stoner, MD, RVT, FACS antegrade flow, and this is a potential source of distal maintain excellent results, practitioners should keep embolization. Avoid unnecessary imaging, especially themselves updated on the evolving best practices to Jeffrey Jim, MD, MPHS, FACS after the lesion has been treated. ensure the best clinical outcomes for their patients.

The information contained herein is for guidance based upon the author’s experience. Individual patient considerations should be taken Minimize Postdilation into account prior to treatment with TCAR. The authors advocate for a more generous predilation MICHAEL C. STONER, strategy, approaching a nominal internal carotid artery MD, RVT, FACS Transcarotid artery revascularization (TCAR) represents a novel, minimal-access technique diameter. This allows for better stent apposition and indicated for revascularization of the internal carotid artery (ICA) in patients with clinically or reduces this risk of prolapsing atheromatous material Chief, Division of Vascular hemodynamically significant lesions. TCAR maintains the benefit of a minimally invasive procedure through the stent during postdilation. Furthermore, Surgery University of while mitigating much of the procedural embolization risk of traditional transfemoral-based stenting. disruption of the plaque earlier during the flow Rochester Medical Center The results of this procedure have been exceptional in both clinical trials and real-world registry reversal duration may be more protective for the Rochester, New York michael_ 1,2 studies. With over 12,000 cases completed to date, a robust evolving training program, and a patients. [email protected] culture of continuous improvement, the procedure continues to be optimized and improved. Disclosures: Case proctor and Always Use Protamine educational consultant for Silk The following learning points were recognized to aid novice users as well as experienced Road Medical. in practice for practitioners to achieve the excellent results seen in TCAR. The intra-arterial manipulation during TCAR mandates more than 20 years. a therapeutically heparinized patient. However, as Realize the Short, but Real, Learning Curve previously mentioned, the procedure time is quite short and the patient is likely to be fully anticoagulated TCAR leverages current skills of most endovascular surgeons (eg, carotid exposure, angioplasty JEFFREY JIM, during incision closure. Cervical hematoma is a MD, MPHS, FACS with 0.014-inch platforms, and stenting). TCAR procedure times have consistently been shown risk that can be mitigated by both careful dissection to be almost 40 minutes less than standard carotid endarterectomy. However, this is still a new Associate Professor, Section and heparin reversal. Furthermore, the use of procedure for novel users. Meticulous procedural techniques are required to realize the efficiency of Vascular Surgery protamine has been shown to eliminate the risk of and achieve the safety of TCAR. Program Director, Vascular bleeding complications, but it was not associated with Surgery Fellowship/Residency 3 Take Time for Preoperative Case Planning increased stroke risk or other complications. Washington University School of Medicine St. Louis, Missouri Attention to the common carotid access site, lesion characteristics, distal ICA anatomy, and Diligent Intraoperative and Postoperative Blood [email protected] intracranial atherosclerotic burden is paramount to the success of this procedure. Careful Pressure Management Disclosures: Co-Director adherence to adequate anatomic requirements is necessary to ensure safe arterial sheath National TEST Drive Program, placement without engaging the lesion. Heavily calcified lesions should be avoided because of the The protective nature of TCAR is generating retrograde flow in the internal carotid artery during education consultant, and case known long- term adverse outcomes (eg, recurrence, thrombosis) with stent placements in these proctor for Silk Road Medical. types of lesions. treatment. Flow reversal and ipsilateral cerebral blood flow are both predicated on maintaining adequate References arterial pressure and relative hypertension during 1. Kwolek CJ, Jaff MR, Leal JI, et al. Results of the ROADSTER Medical Therapy Is the Cornerstone of Safety multicenter trial of transcarotid stenting with dynamic flow reversal. J the procedure. Proactive use of anti-bradyarrhythmia Vasc Surg. 2015;62:1227-1234. Violation of the drug regimen is one of the most common causes of the rare adverse events agents should be applied, and clear communication 2. Malas MB, Dakour-Aridi H, Wang GJ, et al. Transcarotid artery seen in TCAR. Angioplasty and stenting disrupts the intimal-medial interface, exposing blood revascularization versus transfemoral carotid artery stenting in the with the anesthesia team regarding flow reversal Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. flow to a thrombogenic surface. All patients should be on dual antiplatelet therapy to prevent parameters is critical. Postoperatively, hyper- 2019;69:92-103.e2. platelet aggregation. Statin therapy has also been shown to have plaque-stabilizing properties. and hypotension are to be avoided to prevent 3. Schermerhorn M. Transcarotid artery revascularization. Presented at: The beneficial use of these agents has been well-described in the literature and is considered as the Society of Vascular Surgery Vascular Annual Meeting; June 2019. hyperperfusion syndromes or stent thrombosis. standard of care.

AP00589.B TCAR Technique 2019